Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. Blindness after blepharoplasty: mechanism and early reversal. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. 2, pp. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. Freeman EE, Muoz B, Rubin G, West SK. 1992; 99:222. 1 were supplied by the senior author (NJ). If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. This will significantly speed up the recovery time. J. Establishing trust and communication is essential to a doctor-patient relationship, perhaps even more important in a completely elective, aesthetic procedure with high expectations and standards. Remember that the levator aponeurosis is the stage on which the fat removal of upper blepharoplasty is played; and it is natural for early postoperative dysfunction to occasionally be seen. j and k Posterior flap is folded over and sutured into the new inferior lid margin. This area near the nose is called the medial canthus and the same area on the outer eyelids is called the lateral canthus. Dermatol Surg. and JavaScript. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. However, this was not encountered in our patient group. Establishing a good patient-surgeon bond preoperatively is essential to managing any real or perceived surgical complication that may occur. 4, pp. 2020;46:5214. 19, no. 710, 2010. Scott KR, Tse DT, Kronish JW. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. Massry GG. Explain and document how daily visual function is affected. The posterior flap is cut along the new inferior lid margin using Westcott spring scissors and folded upwards to create the anterior lamella of the new superior lid margin (Fig. In more severe cases, the rounding can cause functional deficit with visual obstruction on lateral gaze. In the face of frank orbital hemorrhage with proptosis, a frozen globe, and vision loss, bold measures are called for. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. These can result from skin shortage, middle-lamellar (orbital septum) scarring, and posterior lamellar (retractors and conjunctiva) cicatrisation as seen in Figures 4, 5, 6, 7, and 8. c The anterior flap is created and folded into its new position. Z. Septum must be opened if fat is to be removed, but not the levator. im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. A lateral canthal web is a known complication of blepharoplasty. 316320, 1988. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. Reassuring the patient that privacy will be maintained helps facilitate the patients ability to articulate his or her desired outcome. However, certain caution should be taken to avoid and manage postoperative ptosis. Graves disease: Heaviness of upper lids associated with proptosis may be indication, but disease specific concerns that require special caution include, Dryness related to lacrimal gland inflammation, Exacerbated appearance of proptosis with reduced hooding, Chronic postoperative inflammation related to primary disease, Emotional vulnerability related to thyroidopathy. It is important to tailor the incision upwards at the lateral extent or the hooding will persist. 2003;111:44150. Am J Ophthalmol 1996;121:677. Postoperative patches and bandages are removed in the recovery room to permit early detection of postoperative bleeding. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. I would like to have this corrected as soon as possible and need advice. On examination of the patient, the surgeon must look for ophthalmic and periocular disease by history and a full-eye examination. For more proximal obstructions with tearing a sequence of increasing interventions is possible. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. Please see before/after photo on link below (toward bottom of the website page). The information on RealSelf is intended for educational purposes only. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Lower blepharoplasty is one of the most common facial plastic surgery. Systemic osmotic agents and corticosteroids may be given but do not take the place of prompt pressure release. It is rare that true bony decompression either at bedside through the inferomedial floor or more fully in the operating room is required. 1, pp. Primary acquired cold urticaria. 9, pp. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. These are investigated and followed in the normal fashion for such conditions. Canthoplasty repair for canthal rounding. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. The new superior lid margin is left to heal by granulation. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. Moistened gauze may be placed over the closed eyelids. 3, article 3, 1995. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. Visual field is repeated with the eyelids taped up. Patient selection and patient satisfaction. Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. Inadvertent injury to the lacrimal system should be avoided in upper blepharoplasty by limiting incision medially. 21, no. When needed, lid crease fixation method depends on surgeon's preferences and experience (. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. In one patient there was rounding recurrence. Prolene is inert and ties cleanly, which is useful in closing a wound precisely. Acute orbital hemorrhage requires prompt intervention. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. The risk is failure, with reemphasis, doubling, or other scarring of the existing low crease. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. 5155, 1996. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. 10361040, 1999. Post-treatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, and intravenous steroids until 24 hours of stable vision have been noted. Scars dont run past outside of eye. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in The previous scar is opened up, internal adhesions are widely released (and perfect hemostasis obtained). Twelve patients with post-surgical canthal rounding were included. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. Rapid release of orbital pressure by opening the wound, releasing the lid with a lateral canthotomy with inferior and/or superior cantholysis, is most important. 21, no. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. R. Z. Silkiss and H. I. Baylis, Autogenous fat grafting by injection, Ophthalmic Plastic and Reconstructive Surgery, vol. If a second finger is required in the central eyelid pushing upward, usually a posterior-lamellar graft is required. Figure 10 shows corneal scarring due to severe lagophthalmos. 29, no. Ophthalmic Plast Reconstr Surg. C. D. McCord Jr., The correction of lower lid malposition following lower lid blepharoplasty, Plastic and Reconstructive Surgery, vol. 6, pp. 8, no. Prospective analysis of changes in corneal topography after upper eyelid surgery. 5, pp. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. 3, pp. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. I am 13 days post op. Unfortunately, treatment beyond 1 to 6 hours of total or near-total vision loss is unlikely to be effective. Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. Yaremchuk MJ. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. Upper blepharoplasty can yield significant functional and aesthetic benefits for patients. Am J Ophthalmol 2007;143:1013. Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. Retrobulbar hemorrhage is a form of compartment syndrome, with the orbit bounded by four bony walls and the orbital septum acting as the compartment. ISSN 1476-5454 (online) The amount of lagophthalmos must be such that lower lid elevation would eliminate it. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. Injury to the inferior oblique or less commonly other extraocular muscles, is rare. Consult with a doctor virtually or in person. Antibiotic ointment may be placed over incision. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Patients may usually resume normal activities within 2448 hours after surgery. There were five men and seven women. Ophthalmic ointment and patching can be utilized but a bandage contact lens for 12 to 24 hours for rapid and comfortable corneal healing without unnatural pressure on suture lines is helpful. Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) 1c). It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. Canthal rounding can be cosmetically-unacceptable to patients. 3, no. J. H. Oestreicher, N. K. Pang, and W. Liao, Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients, Ophthalmic Plastic and Reconstructive Surgery, vol. All except one patient reported good surgical outcomes after one procedure. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. Any adjunctive procedures to be performed should also be determined. Minimizing wound dehiscence involves appropriate suture choice and suture placement. All research was conducted in accordance with the Declaration of Helsinki. Up and down gaze photographs document levator excursion.
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